Assessing and Treating Children With Feeding Problems

Episode Transcription

Dr. Nicole:

Hi, everyone. Welcome to the show. I’m Dr. Nicole, and today we’re going to talk about picky eating and feeding problems. This is a topic I know is applicable to so many of you, whether you’re a parent with a child with these kinds of issues or whether you’re a professional working with kids. We eat so many times a day, so when a child has challenges with eating, it becomes really stressful for not only the child but the entire family. And I know some of you may have concerns like how to help your child just eat enough each day, and some of you may be struggling with, “How do I help my child with their restrictive diet that they need to be on due to allergies or other kinds of medical issues when they refuse to eat everything?” And many of those kinds of challenges even in between.

So, there are several different theories and approaches out there about how to address and treat feeding issues in children, but in my opinion and experience, most don’t really address the underlying issues that contribute to these problems. And I was lucky many years ago to come across information about Dr. Kay Toomey and the SOS Approach to Feeding, and I have found it to be the most comprehensive and successful approach to helping kids become better eaters and really, truly more comfortable with a variety of foods. Not just kids who are eating because they’re told to, but kids who truly are comfortable around food, and I’m so grateful that Dr. Toomey agreed to be on the show today as my guest.

Let me tell you a little bit more about her. She’s a pediatric psychologist who has worked with children who don’t eat for almost 30 years. She’s developed the SOS Approach to Feeding as a family-centered program for assessing and treating children with feeding problems. Dr. Toomey speaks nationally and internationally about her approach. She also acts as a consultant to Gerber Products. Dr. Toomey helped form The Children’s Hospital – Denver’s Pediatric Oral Feeding Clinic, as well as the Rose Medical Center’s Pediatric Feeding Center.

Dr. Toomey co-chaired the pediatric therapy services department at Rose Medical Center prior to entering private practice. She acted as the clinical director for Toomey & Associates, Incorporated Feeding Clinic for six years and SOS Feeding Solutions at STAR Institute for eight years. She’s currently the president of Toomey & Associates and acts as a clinical consultant to the Feeding Clinic at STAR Institute. Her approach has been so valuable to me as a clinician and has helped so many families at our clinic here in Grand Rapids. It’s truly an honor to have her on the show today. Welcome, Dr. Toomey.

Dr. Kay Toomey:

Thank you, Nicole. It’s lovely to be here. I really appreciate this opportunity.

Dr. Nicole:

So, I’m curious just for us to start out having you talk for a minute about how you got into doing this kind of work because you’re trained as a psychologist. And was there a specific experience or something in your career that led you down the path of specializing in feeding issues for kids?

Dr. Kay Toomey:

There was, and it is a little bit different path for a psychologist to be involved, so it’s always lovely for me to get an opportunity to speak to my mental health colleagues and families who consult with psychologists, mental health people and find the kind of work you do so very valuable. Because it is unusual as psychologists that this would be a field that we would be involved in, but I got involved in the field very early on in the mid-1980s, and I was asked by a medical team I was working for in a hospital at the time to evaluate a child who had just had a gastrostomy tube placed. And I’m sure a number of people in your audience are familiar with or have children who have gastrostomy buttons.

What we use today, we call them G-tubes, but it’s not exactly where we started. The lovely buttons that we have today are very nice, but what we used to do 30 years ago is we would take an adult urine Foley catheter, we would stitch it into the child’s stomach, we would put a hemostat clamp on the end of it to make sure nothing leaked out. And that was my first experience of working with a child who didn’t eat, is I was asked as the psychologist to come in and evaluate this child who had had a pretty major procedure done. And unfortunately the prevailing belief at the time, and some people still believe this today, is that when children don’t eat, it’s the parent’s fault.

And so of course as a psychologist I was supposed to come in and help do parent coaching to help the family. And what I discovered is I had a warm, delightful set of parents who were doing everything anybody told them to do, none of which really worked for their child, because she actually had a physical problem. It was getting in the way of her being able to eat, and that’s what got me interested in the field, because I wanted to know as a psychologist, why do we blame parents when kids don’t eat? And there’s certainly lots of history behind that, as most of us who are parents know, we often get the blame for lots of things, and we also blame ourselves for lots of things as parents.

And so what the research actually shows is that the parents are the cause of the child’s feeding problems in only about 5% to 8% of the cases. And we really have some good, new research that’s come out in the last three to five years that proves that point over and over again, that as parents we don’t cause our kids’ feeding problems for the most part. Unfortunately, there’s things we do as parents that can help make our children’s feeding problems better and there are things we do that make it worse, because there is a lack of understanding out in the field I think, and even for many parents, that eating and feeding are actually learned behaviors.

People think eating is automatic, it’s instinctive, it’s natural, it happens no matter what, kids are just going to do it, and unfortunately that’s not true. We know that eating is driven by your instinct only for the first four to six weeks of your life. After four to six weeks, your appetite instinct actually changes a bit and your primitive motor reflexes takeover to help drive you to eat and gain weight until about four to six months of age. After four to six months of age, those reflexes for eating go away, and if you haven’t brought all the motor movements you need to eat under voluntary control, if somebody hasn’t been helping you learn how to do that, when your reflexes go away, for some children, their eating goes away.

Around the world, there’s actually a fairly new study that indicates one of the most common ages to get a gastrostomy placed is around six to seven months of age. And oftentimes that’s because something physical was going on with the baby that was significant enough that interfered with their ability to learn how to eat. After six months of age, eating is essentially a learned behavior. We only have one reflex for eating left into adulthood, only one, and so you have to, as a child, have somebody who can help teach you how to eat. As parents, we understand that we have to teach our children to talk, we understand that we have to teach them to walk, and we have to teach them how to use the toilet, right?

But somehow we think eating just happens and that there isn’t learning involved, when in actuality it’s very much a learned behavior. And when you have a child, and I know some of your audience are professionals, so when you have your own child or when you have a client who is struggling from a neurodevelopmental standpoint, who has some kind of physical issue, feeding is oftentimes where it falls apart. We talk about in our approach, the SOS Approach to Feeding, that feeding problems are not all in the kids’ heads.

They’re not all in the parents’ heads either. Eating problems are all in the kid’s body, and when children don’t eat like we think they should eat, they don’t grow well, they don’t eat a widely varied diet. It is because something about that child’s body isn’t working correctly, and we just need to be smart enough and persistent enough as the grownups to figure out what that is. What’s the problem here? What makes eating so difficult for your child, for your clients?

Dr. Nicole:

I think that’s such a helpful way of looking at it, because as you mentioned so often that there’s just a lot of negative emotions involved in this, right? Whether it’s parents, or other people blaming the parents, or people blaming the child, and what you just said there I think is such a powerful reframe of know when a kid’s struggling with this, it’s because there’s something going on underneath this that we need to kind of get curious about and do some detective work and figure it out. And boy, does that take a lot of the personal emotion out of it, right? It’s not about the kid being bad or the parent being bad or stubborn or whatever. It’s about we need to get in here and figure out what’s going on and why this is a problem for the child.

Dr. Kay Toomey:

Exactly. I think a good way to think about it is, “How do we join with our children to figure out why for them eating is not going as well as it should be?” And in fact, for some of our children, it almost seems like not eating works better for them than eating.

Dr. Nicole:

Yeah.

Dr. Kay Toomey:

And we like to talk about in our program that the feeding problem is what you see. That is literally the tip of an iceberg, and that is how we talk about it. So, the feeding problem is up here at the tip of the iceberg, but it’s what’s underneath the water that crashes your ship, right?

Dr. Nicole:

Yeah.

Dr. Kay Toomey:

And actually, it’s part of why we use the term SOS Approach to Feeding. For us, the term SOS actually stands for Sequential Oral Sensory, because those are the major components of our program, but we also know that SOS means, “Save our ship.” And if you’ve hit this iceberg of feeding, you potentially are going to sink your ship if you’re not getting the help that you need, because there’s actually seven areas of human functioning that are involved in the process of eating.

And eating is literally the only human endeavor you will ever do in your entire lifetime, where you have to have each one of those seven areas working correctly, and on top of that, you have to be able to integrate across all seven areas. And that’s why kids can look okay when they’re playing, they can look okay at school, they can look okay at this self-help skill, but for some children, it’s eating where it all falls apart because they don’t have all seven areas working quite right, and/or they can’t put all seven areas together every time they come to sit down to the table.

Dr. Nicole:

Yeah. We do so take for granted that this is just something that works for kids, right? This is just you sit down and you eat, and we don’t even think about all of these underlying skills.

Dr. Kay Toomey:

Sit down, eat.

Dr. Nicole:

That’s right.

Dr. Kay Toomey:

In SOS, we talk about the fact that there are 32 steps in the process of learning to eat, and I think for much of your audience, that may come as a surprise. If you had a child who is very, very typically developing, they may learn to eat a new food in about 25 steps. We find for children who have various feeding problems, the average is closer to 32, but if you’re the parent of a child who has autism, you’re probably going to have 40 to 60 steps in your child’s feeding hierarchy, what we call the steps to eating. If you have a child with an oral motor problem, and I’m sure some of your audience have children who have speech delays, have oral motor challenges, it can be as many as 60 steps in that hierarchy as well. It really depends on, for your audience, how medically complex their child’s situation is.

Dr. Nicole:

What I think is so helpful about that though, while it may sound overwhelming initially to people, like, “Oh my goodness, 60-some-steps,” what I found so empowering about that as a clinician when I first started taking your courses is it gave me a tremendous amount of hope that, “Okay, that may be a lot of steps, but there are things we can do here.” Because we often see kids in the clinic who are now into their teen years still struggling with these kinds of things and it’s like while it may feel like a lot of steps, in the scheme of a child’s lifetime, taking the time to slow down and work on those things is so valuable.

Because otherwise one year leads the next, the next, and before we know it, we’ve got a teen or a young adult who still is struggling with these things. And so it gave me such a good amount of hope of, “Okay, so there are systematic things that we can do here to impact this,” and that’s really what I want. Especially parents who are struggling to hear, is there is a system here for how we can go through this. There are steps that you can take to help your child with this.

Dr. Kay Toomey:

Absolutely. Absolutely. And I oftentimes talk, especially an older child, but to families as well, about the fact that the whole process of learning to eat is a little bit like being in school, and learning how to do math or learning how to read or learning how to do science. In fact, we oftentimes refer to our clinic as food school because of that, and just like you would not expect a third grader to do sixth-grade math, you know that if you teach that math one step at a time, they will learn over time to do sixth-grade math. That when you follow a series of steps, the children can accomplish the next step and get that under their belt, and then they’re ready to go to the next step.

I think, because as parents we think it’s two steps, you sit down and you eat, we miss so many of the steps in between, and if we just knew what the next step was, then we could help teach our child how to master that. And once they have that, then we teach them to master the next step, and some people think it’s a little bit like teaching a child a sport. Or the analogy we sometimes use is, “How would you teach a child who’s afraid of the water how to swim?” The philosophies are kind of two about how you do that.

One philosophy says you let the child play next to the water for several days until they’re comfortable, get their toes in several days, go up to their knees several days, up to their neck several days, hold onto the side of the pool, eventually put their face in, pick their feet up, and we know that that is a successful way to teach children how to swim. And then you work on the fancy strokes, right?

Dr. Nicole:

Yeah.

Dr. Kay Toomey:

Once they have the basics down. The other philosophy about how to teach a child who is afraid of the water how to swim is you take them to the deep end and you throw them off the edge of the pool, and that’s the way it is in feeding too. There’s really two major approaches to work with kids who have feeding difficulties. One is what’s called systematic desensitization, which is that slow stepwise, up forward approach. The other’s called flooding, which is more about you start at the highest step, make them do that highest step with the assumption that then all the lower-level skills are automatically in place. And for those of your audience out there who live with a child who doesn’t eat, they know that’s not true. Just because their child can eat this food over here doesn’t mean they can eat this food over here, but eating is more of a skill than what I think a lot of people realize.

Dr. Nicole:

Absolutely. I want to get into kids who have these problems. Let’s break down a little bit, because you have certainly worked with so many children over the course of your career. Let’s talk about when are children most likely to become picky eaters. Who are those kids? What are their characteristics? What are the things that kind of set kids up to be picky eaters, and why does that happen?

Dr. Kay Toomey:

That’s a great question, a complicated one, but a great question. So, we know there are approximately five major transition time periods in a child’s life, maybe six during which they are going to be more at-risk to develop feeding problems. The first one actually is going to be that four-to-six-week timeframe, because for some children, when the appetite drive changes, their physical issues are significant enough that the reflexes aren’t working quite right. And when that instinct is no longer so big that it’s going to make you eat no matter what, no matter how, for some children, we see them actually begin to falter between four to six weeks. And generally, that’s going to be a child whose physical issues are, as I said, significant enough that it’s interfering with their reflexes.

The next major time period is going to be around that four-to-six-month time. During that time period, children are going to lose those motor reflexes, primitive motor reflexes that we’re born with. Most people are familiar, for example, with routing. If you stroke a child’s cheek, they will turn and open their mouth, so we have a number of little ones like that. My favorite is the palmomental. If you put your finger in the palm of a baby, they will close their hand on your finger. What most people don’t realize is they also open their mouth, and so you can use that to help with latching as well.

So, for children who have various medical issues going on in those first four to six months of life, children who have gastroesophageal reflux, children who have food sensitivities or food allergies, children who have other major medical diagnoses, sometimes those physical problems are enough to interfere with the child actually being able to learn how to bring all those muscle patterns under voluntary control versus relying on the motor reflexes. So, when the reflexes go away, their eating goes away. A classic example of that is going to be the baby who does what we call dream feeds.

And dream feeding is a baby who eats best when they’re asleep and to the point where either they put themselves to sleep to eat or parents will put the child to sleep to eat. So, I don’t mean the baby who’s at the end of their feeding, their bottle or breastfeeding. They’re happy, they’re full, they drift off to sleep. That’s not when I’m talking about when I’m talking about the baby who has to go to sleep almost in order to be able to eat, because we stop sleeping so much after six months of age, and you can’t be so reliant on the reflexes anymore.

The next time is going to be around 12 to 14 months of age, and this is where you and I as psychologists come in, because around 12 to 14 months of age, children become self-aware. Little, bitty babies don’t know that they are their own person on the planet. Little babies think they are the planet. They think they are the world, they think they are the same organism, “Everything in the world happens because of me.” That’s why we call it the stage of narcissism, but around nine months of age, babies begin to crawl.

So, we used to have what we call a symbiotic relationship. We’re all the same people to a baby’s mind, but as they begin to crawl away from their primary caregiver, cruise away from their primary caregiver, walk away from their primary caregiver, babies learn that they are their own person on the planet, and so we talk about they become self-aware. When babies become self-aware, they want to start doing things themselves, and so they don’t want you to spoon feed them anymore. Plus, if you think about as a grownup, we’re self-aware. If you think about as a grownup, when somebody says, “Here, can I feed you some of my soup,” or, “Do you want to taste some of my salad?”

Most of us are like, “Wait, wait, wait. Give me a minute, give me a minute,” because being fed by other people is actually kind of uncomfortable. They spill on you, they put the spoon in too far, they don’t give you enough food, so once babies become self-aware, they don’t like to be spoonfed so much. And when you have a child who wants to do it themselves but doesn’t have the feeding skills to do it themselves, this is going to be the other major place where we see kids falter from a feeding standpoint, because we as parents want our kids to eat a table-food diet. But for some kids developmentally, they can’t handle a table-food diet.

And now we have parent and child headbutting because the child wants to do it themselves. They don’t have the skill, and families don’t know how to help. And around the world, the second most common age to get a gastrostomy tube just unfortunately is around 14 to 16 months of age, and it’s because the child doesn’t have adequate skills. So, again, it comes back to the physical and how the body is put together. So, they don’t have the oral motor skills, they don’t have the motor skills, the sensory motor skills to do the task of chewing and swallowing a textured piece of table food, and so things fall apart there.

The next three times where kids are going to potentially turn into picky eaters is our terrific two-year-olds, and there are some good developmental reasons for that, so between two and three. And then there’s going to be another stage around five to seven, and there’s yet another one at nine to 11. And what we see during those major age ranges, two to three, five to seven, nine to 11, is children are making big developmental changes in the way they think about the world or their cognitive development. And when children are making big developmental leaps forward in one area, another area of development sometimes regresses.

Berry Brazelton, the pediatrician, called this a touchpoint. And the part of development we see regress when our mental skills go forward is our sensory tolerance for the world, and so in each of those age ranges, a child’s whole way of understanding the world changes. Because of that, they’re more aware of the world around them, but nothing feels good, because all their sensory systems just took a hit, just regressed. And then we’re going to throw in with our terrific two-year-olds that they have to finish the last stages of self-identity, which is not just who am I as my own person on the planet, but who am I as my own separate person than my parents and my family, or what’s called separation in individuation.

And that’s why your two-year-old does the opposite what you want them to, is because if I do everything the way you want me to, how do I know if I’m me or I’m you? So, two-year-olds do things in opposition, not because they have oppositional defiant disorder, but because the best way for them to figure out who they are as separate from my mom or dad is to do the opposite of what my mom or dad told me too. Yeah, I call being two the perfect storm.

And what you’re going to see from the research is if you ask parents, “Is your two-year-old very picky or sometimes picky or not picky at all?” 50% of parents are going to say their child is either sometimes picky or very picky. So, between two and three, 50% of parents are reporting their child has become picky, so there’s some important things we need to do during those age ranges as parents to help prevent picky eating from lasting, as well as how to make living with a two-year-old who’s a picky eater easier.

Yes. We could do a whole separate episode just on that, right? How to live with a two-year-old. I want to circle back in a moment to what parents can do to help prevent those patterns from continuing, but first I do want to touch on … So, a significant number of kids at that developmental phase do go through some amount of pickiness, but what we see is some kids who kind of move through that and go then into more varied eating patterns, and some kids who don’t, who stay very picky, and some kids who that actually gets worse over time and would branch into what I know you call a problem feeder. Unfortunately.

Dr. Nicole:

Before we get into strategies, I just want to have you differentiate for our listeners, how do you define the difference between a child who is a picky eater and one who is a problem feeder?

Dr. Kay Toomey:

I think that’s a really great question, and it’s a really good point that you’re making, because there is another belief out there. A, that all kids are picky, and B, that all kids outgrow it. And again, really in the last three years we’ve gotten some very good data that indicates that even though when you ask parents of two-year-olds who’s picky, about 50% of parents are going to report their children are picky. If we look over the first decade of children’s lives, what the research shows is actually about a third of children will experience picky eating that’s significant enough that it interferes with their food range at some point in that first decade of their life, so about a third of children have picky eating that’s a little more significant.

Dr. Kay Toomey:               I think that’s a really great question, and it’s a really good point that you’re making, because there is another belief out there. A, that all kids are picky, and B, that all kids outgrow it. And again, really in the last three years we’ve gotten some very good data that indicates that even though when you ask parents of two-year-olds who’s picky, about 50% of parents are going to report their children are picky. If we look over the first decade of children’s lives, what the research shows is actually about a third of children will experience picky eating that’s significant enough that it interferes with their food range at some point in that first decade of their life, so about a third of children have picky eating that’s a little more significant.

We first want to look at how many different foods that child eats, because the number of foods the child eats that are different is going to differentiate between a picky eater who may outgrow their picky eating and a child who really is a problem feeder. And so we find that children who are picky eaters have about 30 different foods in their food repertoire. Now, when we tell parents that they all are like, “No kids have 30 foods, especially feeding with your two-year-old.” That’s because you’re thinking like a grownup, not like a child. To a child, if food is different based on how it looks, how it feels in the mouth, how it tastes, how it works in the mouth, that’s what makes the food different.

So, to a child, a Goldfish cracker is actually completely different food than a saltine cracker. They don’t look alike. They don’t work the same in your mouth. One’s cheesy, one’s very salty. We talk about a lot in our classes for professionals that for children who have … Well, any child, a chicken nugget is a very different food than breast of chicken, right? Because a chicken nugget is a small, round, brown, breaded, warm, what we call pre-chewed piece of meat. That’s why children like chicken nuggets, fish sticks, hotdogs, bologna, is because they’re all pre-chewed by the manufacturer so kids don’t have to do the work.

But that’s really different than a baked breast of chicken or a chicken breast that you grilled. It’s not going to look the same, it’s not going to taste the same. The only thing that’s the same is the animal it came from, but that doesn’t mean a lot to the kids, especially the young ones. So, foods are different based on specifically what they are, not on their category, so if your child eats a French baguette, that’s a really different food than a croissant, because you have to really work your mouth different. Apple sauce is a completely different food than apple juice, than a real apple, so hopefully that will help parents a little bit.

Because what we ask our families to do when we first meet them is we ask them to sit down with a piece of paper, make three columns on a piece of paper, put at the top of one column proteins, the next one is starches, the next one is fruits and vegetables, and we want the parents to write down exactly every food their child eats. 80% to 90% of the time you present it to them, they take at least one or two bites. So, we’re not interested in volume, we’re just looking for rain.

Dr. Nicole:

Wow.

Dr. Kay Toomey:

When you do that list, kids who are picky eaters are going to have about 30 foods. When we do that list with families, children who are problem feeders are only going to have about 20 foods or fewer, so we have to remind parents don’t forget things like nuts and seeds and pinto beans and rice and corn and milk, because sometimes we forget those things. And if your child eats cheddar cheese, that’s really different than mozzarella string cheese, so that’s going to be one of the things that tells the difference between the children. The other thing we see, actually all of us do as human beings, is we liked to eat the same foods over and over again, and I’m sure some of your parents on the audience are thinking, “Oh, I get in such a rut with what I cook, or all my child wants every day is macaroni and cheese. And every time I ask them what they want to eat, they say macaroni and cheese.”

We know that as humans we find it comforting to eat the same food over and over again. It’s actually in the field referred to as a food jag, so when your child or you want to eat the same food over and over again prepared the same way, that’s called a food jag, and as I said, everybody does it. That’s why as grown ups, most of us have two or three boxes of half-eaten cereal in our cupboards, right? Because you get about a box and a half in and you’re like, “I don’t want to eat it anymore.” So, that’s the other phenomenon that happens with food jagging, is eventually you get sick and tired of it.

For those of us who don’t have feeding problems, if we burn out on a food we’ve been jagging on and we take about a two-week break, we’ll come back and eat that food again, and that’s what picky eaters will do as well. If they get sick and tired of a food, give them about a two-week break, re-present it and they will likely eat it again. Children who are problem feeders, they don’t eat that food again. When you give them a two-week break, you re-present it to them, they act like, A, they’ve either never seen it before in their life, or it’s the worst possible thing on the planet you could possibly feed them. And so that’s a big, distinguishing feature between those two groups of kids.

When you do that food list that we were talking about, what you’re going to find with the picky eaters is they have at least a couple of foods in each of the different categories. Even if the only fruits and vegetables they have is apple juice and apple sauce, they at least have those. Most kids don’t have a problem with starches, but some kids may only have milk, yogurt and cheese as their proteins, but they’ve got something in each one of those columns.

So, the picky eater is going to have at least one or two foods in each of those different columns. The problem feeder may be missing an entire column, so they may miss an entire nutrition group or they may miss an entire texture group, so some children won’t eat any purees at all. Some children won’t eat anything that’s crunchy, some children won’t eat anything that’s chewy, and so that’s another way to look at the difference between the picky eater who may outgrow it and the problem feeder who needs help.

Another way to tell the difference is when you give them a new food. So, your picky eater is going to fuss at you, they are going to whine, but eventually they settle down, and maybe they’ll take a bite of that new food and maybe they won’t, but they settle down. The children who are problem feeders, if you give them a new food, it’s a big tantrum, crying, screaming, throwing, yelling, crawling under the table, running out of the kitchen. That’s what you see the problems feeders do, so that’s a pretty good way to tell the difference as well.

Another difference with a picky eater is generally the child who’s the picky eater will eat some of the same foods as the family eats. Usually. Not always. There’s something being served [inaudible 00:35:44] meal that the picky eater can find that they’re going to eat, even if it’s just the bread, or even if it’s plain pasta, or even if it’s just the pizza, or even if it’s just a milk. There’s something at the family meal that those kids can find to eat. Problem feeders, they eat completely different foods than the rest of the family at the family meal. The parents are oftentimes getting up and making a separate meal, or the child is getting up and making a separate meal, especially if you have an older child. They will oftentimes just get up from the table and go get a peanut butter sandwich or something, soup, a protein bar, something.

Dr. Nicole:

I find for those families too, or the kids who are really problem feeders, those are the parents who can relate to they’re packing food in baggies and things whenever they go where they have to make sure they always have that child’s foods that they can eat. Because they could be out somewhere and if it’s not available their child just won’t eat for a longer period of time then. If you’re having to pack just certain special things and carry them with you all the time to make sure your child can eat, that would be an indication too, right?

Dr. Kay Toomey:

Very much so. That’s a really good red flag, and I think that will resonate with a lot of your families. Another thing that tells the differences about how long it takes the child to learn to eat a new food, the picky eaters, like I said, because they fuss at you, they seem to have to see a food a number of times, and it seems like it takes them a lot of steps to learn to eat a new food, but they will learn to eat a new food maybe in about 25 steps or so.

The children who are problem feeders, parents are going to describe them as it’s like it’s pulling teeth, getting them to do anything new, right? We’ve had families say to us, “It’s like my child has to see this food 60 different times before they’re even willing to touch it, much less taste it.” And so that’s the piece you see with the problem feeders, is it takes longer for them to get used to a new food and it takes longer for them to learn how to eat a new food.

And then for -I was going to say, I think that that’s so helpful for people, for parents to just understand the difference between those things, because so often kids all just get lumped in one category, so as a picky eater. And as you mentioned earlier, the prevailing advice is just, “Well, they’ll grow out of it,” and we’ve got this percentage of kids that doesn’t and really develops these problematic feeding patterns. I want to make sure in the time that we have left here to give people some straightforward or practical strategies. For the parents who are listening or the professionals, they’re like, “Yes, this is exactly what I’m dealing with all the time.” What are some practical things that parents can do to help their children eat better?

Right. The first major thing for families to do is to not let their children food jag. Food jagging is really how you take a child who’s a pretty good eater, and when they hit the terrific twos, you turn them into picky eaters, because we let them eat the same thing over and over and over again. And unfortunately as professionals, that is advice that a lot of professionals give families, “All kids are picky, they all outgrow it. Pick your battles. If your child wants to have hotdogs every day for lunch, just let them do that.”

Right. The first major thing for families to do is to not let their children food jag. Food jagging is really how you take a child who’s a pretty good eater, and when they hit the terrific twos, you turn them into picky eaters, because we let them eat the same thing over and over and over again. And unfortunately as professionals, that is advice that a lot of professionals give families, “All kids are picky, they all outgrow it. Pick your battles. If your child wants to have hotdogs every day for lunch, just let them do that.”

But what we want is for families to give their kids completely different foods at every meal and snack across two full days, so if your child has a food today, they don’t get it again today and they don’t get it tomorrow either. The only caveat to that is milk, and so otherwise if your child has a food today, don’t give it to them again today, and they don’t get it tomorrow either. You can give it to them the day after tomorrow. We know that simply doing that helps to prevent a large percentage of the picky eaters in the first place, and it helps your child in the two-to-three-year age range who does get picky not turn into that problem feeder.

The other major important thing actually is to have some structure to your meal times, and I know that’s so hard for us as families. It’s so hard for us. We are so busy in this modern age, and unfortunately many families in the US … And in fact, I happen to be privileged to speak around the world. Many families around the world are serving up their children’s meals at the stove or the kitchen counter, presenting a whole plate of food to their child. Their child is like, “What is that?” And unfortunately, when you cause your child’s stress at the beginning of a meal by giving them a bunch of things they can’t handle, you make their adrenaline go up, and adrenaline literally makes your appetite go off.

And so it’s a problem that we have to think about slowing the mealtime process down. We need to give kids a warning first, “We’re going to eat in five minutes.” When you go to get them, don’t say, “It’s time to eat now.” You’re going to say, “It’s time to wash hands now,” because they need a transition activity before they go to eat. And that way when your two-year-old says, “No,” you’re power-struggling about hand-washing, not about eating.

Dr. Nicole:

Yes.

Dr. Kay Toomey:

Hand-washing is a lovely hygiene habit to get your kids into, so five-minute warning, have them wash their hands, then they come to the table. And the biggest thing that parents can do to help their children learn to eat new foods is to go back to family-style serving, not to serve at the counter, not to serve at the stove. Bring the serving dishes to the table, pick up the first food saying, “We’re having spaghetti and meatballs. I’m going to take some spaghetti, put it on my plate here. Joey, you can have some spaghetti. Pass it to your sister. Susie, you can pass it to your dad.”

Even if Joey decides he’s not going to eat any of that spaghetti, he learned about what it looked like, he learned about what it smelled like. He may have got served a piece with his fingers. He might have learned about how it felt in his hands, and that’s the way we actually start teaching kids to be accepting of new foods, is by doing the family-style serving, so it approaches and then they get to move it away, because that helps as well. When the kids are in charge of serving themselves, doing it themselves, they’re going to be much more willing to do it than if we as parents just do it for them.

And then certainly we want to have the clear end to your meal as well, so as parents we’re in charge of when cleanup happens, and we’d like kids at the end of the meal to at least be able to help clean up all the different food and clean up all the different dishes, because when kids are cleaning up, they know no one expects them to eat anymore. And I think parents will be surprised at what their children will do if the child knows the food’s either going in the trash or it’s going up on the kitchen counter or it’s going in the compost bin. It is amazing what kids will do if it’s being cleaned up. That’s the way we think about mealtime structure, and we know preventing picky eating and having a structure to meal times are going to be the two most important things that parents can do to help their children with their eating.

Dr. Nicole:

So practical and helpful. And for people who are listening who either are … Their child is kind of veering in that direction or they’re trying to prevent that. Such helpful things. And the whole issue of creating structure around meal times, that’s just so beneficial for a host of reasons beyond teaching the feeding skills, right?

Dr. Kay Toomey:

Right.

Dr. Nicole:

The relationships, the communication, the mindfulness, I mean, all of that, so talk about killing multiple birds with the same stone.

Dr. Kay Toomey:

Right.

Dr. Nicole:

Having structured sit-down family mealtimes is just so beneficial for so many reasons, so I love those strategies as proactive strategies. What would you say to the parents who are listening who are like, “Okay, I hear that. I can start to implement that, but I definitely already have a problem feeder on my hands?” And maybe, because we see this in the clinic a lot, families who have been to multiple professionals, went to multiple things, what would you say to those families as a helpful next step or what they should pursue or what they could work?

Dr. Kay Toomey:

I think there’s a couple of different things that families can do if they really feel like they have a child who’s a problem feeder already. Certainly, one thing that would be helpful is to get some assistance, because as a parent, kids eat so often. Depending on the age of your child, they’re eating somewhere between four and 11 times a day. And I always say, “How many things do you do with your children repeatedly every day where you have the opportunity to feel like a failure?” And eating is oftentimes it, so getting some help I think makes a big difference.

And so having the child be in some kind of feeding therapy is generally what we’re going to recommend, and there’s a couple of different options of how to think about doing that. In the SOS Approach to Feeding program, we have just recently redone our entire website to be more accessible to parents, and parents can actually go onto our website and get a number of free resources certainly. But they also have an option to become a member of the SOS community, and if they become a member, they will get access to just a ream of information, so many different resources. And it also gives them access to consult with one of the SOS faculty and to really find somebody who can give them what might be the next step for their child, how can we think best about where to go next with their child.

And it may be that we feel like certain resources on our website are going to be sufficient and that will be what is going to help, and it may be that we then recommend that the family go ahead and see a therapist. We certainly would recommend that families see an SOS-trained provider, but there are many different kinds of feeding programs out there. And I think the big thing is to try to access the professionals who specialize in working with kids who don’t meet. We know that a lot of families are in various programs where the therapist they’re seeing is supposed to be a jack of all trades and be able to do OT, PT, speech, mental health, dietary, and that therapist may not be trained as an expert in working with kids who don’t eat.

If you have a problem feeder, you really need somebody who specializes in working with children who don’t eat, so that would be the first thing I would suggest if people are looking for a therapist, is ask questions, “Does this person have a specialty in working with kids who don’t eat?” And certainly they can find that on our website as well, and one of the resources for parents on our website is to search for an SOS training provider in your community.

If the family has been in feeding therapy and they’re not finding it successful, I would recommend they shift to a different approach and a different philosophy about how to help their child, because no one program works for every child. And it’s important as a parent for you find the match for you and your child that fits for you and your family. So, those would be probably the two things I would say. If you really feel like you have a problem feeder, it’s time to at least get some level of a consultation, get some resources that you can access and then potentially get a referral to a feeding therapist.

Dr. Nicole:

Yeah, and I would wholeheartedly agree, and I love that your team is offering those supports now through the resources on the website and the consultation. Because while it is a very family and parent-centric model, parents need the guidance from the professionals of, “Okay, here are the sensory pieces or the oral pieces or the cognitive pieces that we’re going to work on next.” And then many parents can take those things and run with it, but to be able to have the guidance and the structure of that and all the resources that you provide I think is so very beneficial, because you can’t do this alone.

Dr. Kay Toomey:

You can’t.

Dr. Nicole:

In my opinion, when you have a problem feeder, and as Dr. Toomey was saying, there’s just so many times a day that you’re faced with having to deal with feeding your child. The amount of anxiety and stress that builds for you as the parent, that builds for your child, it just really is something that I feel is very important, to have somebody in the professional realm come alongside you to guide that and to just even help reduce everybody’s stress and anxiety around it.

Dr. Kay Toomey:

Right, I agree. I say children have emotional antennae, and there are certain emotions, unfortunately that are contagious, and anxiety is one of them. Stress is another one of them. Frustration I would say is another one of them. And we know that it’s hard as a parent to do that deep breath and go into every meal with a child who doesn’t eat well with my happy face.

Dr. Nicole:

Right.

Dr. Kay Toomey:

So hard as a parent to do that.

Dr. Nicole:

Yeah, yeah.

Dr. Kay Toomey:

I was lucky enough to be in the field for 10 years before I had my child with a feeding problem. The universe always has lessons for you to learn. And so my daughter was born at 35 weeks, so she was premature, and she had pretty significant gastroesophageal reflux and had her first ear infection at three weeks of age from refluxing into her Eustachian tubes. And I knew what I was doing and it still made me crazy. As parents we have to be gentle with ourselves, and we have to recognize how hard this is and that it’s important to get help for ourselves. It’s important to reach out to somebody, because you’re right, when you have a problem feeder, you can’t do it by yourself.

Dr. Nicole:

So, I want to make sure. Share with everybody, what is the website? We’ll have it in the show notes too, but for those who are listening, to be able to hear it now.

Dr. Kay Toomey:

So, it’s www.SOSapproach.com.

Dr. Nicole:

Easy.

Dr. Kay Toomey:

And so pretty straightforward, and people can just go onto the website and start searching for resources.

Dr. Nicole:

Fantastic. Such a great resource, and I highly encourage all of you who are listening to go check that out, for sure. Dr. Toomey, thank you so much for being here today. You’ve shared such an immense amount of just insight and information, and I know people will find that so helpful, so thank you for your time.

Dr. Kay Toomey:

Well, thank you for having me. It’s been wonderful.

Dr. Nicole:

And thanks to all of you for listening today. We’ll catch you on the next episode of The Better Behavior Show.